Wound Care Flashcards
What are the four stages to wound healing?
Hemostasis
Inflammatory Phase
Proliferative Phase
Maturation Phase
What is the Hemostasis phase of wound healing?
Hemostasis
* Immediate; 0 - 2 days
* Thrombin converts to fibrinogen
* Coagulation from dilated vessels
What is the Inflammatory phase of wound healing?
The body’s protective response to injury
* 2 to 4 days, pain, redness, heat, swelling and loss of function at the site of injury
* If > 48-72 hours, look for evidence of new or ongoing tissue damage or infection
What is the Proliferative Phase of wound healing?
- 4 to 21 days in length
- Rebuilding tissue; Filling by granulation, contracting the wound through contraction and converting the wound through epithelialization
- Includes remodeling; Strengthens
What is the Maturation Phase of wound healing?
Maturation Phase
* up to 2 years Wound gains tensile strength
- wound appears healed but Collagen production and reorganization will be ongoing for years.
What is Palliative Wounds?
Not going to heal = “palliative wounds”
Patient and wound related factors mean there is no potential for
healing
What are the Palliative Wound Care Principles?
Key Principles
* Prevent wound development / deterioration
* Correct / treat underlying cause
* Control wound related symptoms
* Utilise patient self-assessment
* Provide psychosocial support
* Promote independence
* Improve quality of life
* It is NOT an excuse for poor wound care
What are issues with hard to heal wounds?
Living with a Hard to Heal Wound
* Pain, exudate and malodour
* Anxiety, depression, self-neglect
* Loss of self-esteem
* Loss of control
* Social isolation
* Poor sleep
* Role functioning (work, financial, mobility)
* Inconvenience (dressings, clinic etc)
What does wound Assessment involve?
Assessment the Whole Person
General condition of the patient
Medical and surgical history
Contributing factors that may impair healing
Pain
Wound Assessment and Plan
What is on wound assessment form? DHB
Initial goal
Diagnosis
Factors that may impede healing
Intermittent Goal setting
Discharge planning
Wound measurement
How to measure wounds?
Consistent method for measuring longest wound length and widest width
Use Clock face to describe e.g. 9 cm sinus at 12 o’clock
What is probing and how should you do it?
The act of using a long instrument to examine a patient’s body
Don’t Use Metal Probes
Use soft tipped Measurement Probes
Probing should be done gently by competent clinician
What are the four kinds of conditions a wound bed can be?
Dry eschar/ Black Necrosis
Yellow slough
Granulation tissue
Epithelising
What is yellow slough?
Yellow slough you don’t want. Yellow slough is waste material that the body produces. Its not healthy.
What is Granulation tissue?
Granulation tissue is a type of new connective tissue that forms in wounds as they heal. It is an important component in the wound healing process
What is necrotic tissue?
Necrotic tissue is dead or devitalised non-viable tissue which impedes wound healing. Can delay wound healing.
What is Epithelising wound tissue?
The process by which the epidermal cells regenerate and migrate to cover a wound is called “epithelialization.”
Epithelializing wound tissue is the process of repairing a wound by regenerating and migrating epidermal cells to cover the wound. It’s the final stage of wound healing and occurs during the proliferative phase.
What is Exudate Level?
Exudate level refers to the amount of fluid that drains from a wound during the healing process
When assessing Exudate Level, what should you include?
- Condition of the current dressing
- Frequency of dressing
- Dry dressing indicates low exudate
levels - Leaking dressing indicates higher level
Moist- little fluid on dressing
Wet- Small amounts of fluid on wound dressing marked
Saturated- Excess fluid on wound
What are the kinds of exudate Type and Level
Exudate Type consistency and odour
Serous (clear, straw colour)
Purulent (cream or green)
Haemopurulent (red, brown) may
indicate infection
Malodour - may indicate infection
or fistula
What are kinds of Pain Treatment for wound dressing?
Coordinate care with pain medication administration
Premedication – Short acting opioid/booster dose
Entonox gas
Nerve block
Use “Time out”
Keep wound covered using a non-adherent dressing
Reduce frequency of dressing
Consider using topical opioids/anaesthetics
Non pharmacological strategies
What are treatment objectives for wounds?
Debride
Donate Moisture
Reduce bacterial burden
Absorb Moisture
Protect New Tissue
What is the purpose of wound cleansing?
To remove
Debris (e.g. Surface contaminants, dressing remnants)
Desvitalizad tissue
Microorganisms
Exudate
In wound care what do you do with dead space?
Dead space must be filled with dressing
material to ensure that wound closure is delayed until the space has been replaced with granulation tissue:
* Cavity
* Undermined tissue
* Tracts
* Make sure you can get it out in one piece!
